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INTRODUCTION: Advanced stage renal cell carcinoma (RCC) with and inferior vena cava (IVC) thrombus is associated with poor clinical outcomes. This report details the results of a multidisciplinary surgical team who addresses the surgical component of Stage III and IV RCC.
METHODS: A retrospective inquiry of our vascular database from 2003 to 2012 identified 55 surgical cases done for Stage III (n=40) and Stage IV (n=15) RCC. The character of tumor and IVC tumor thrombus was evaluated by clinical staging preoperatively and pathology staging postoperatively. Patient demographics and surgical reconstruction is detailed. Reconstructions were evaluated by oncologic surveillance with computed tomography (CT) or magnetic resonance (MR) imaging. Patients received venous thromboembolism (VTE) prophylaxis. Antiplatelet therapy was continued if indicated medically. A Clavien-Dindo classification (CDC) of early (<30day) surgical complications and mortality was recorded including a review of secondary surgical interventions.
RESULTS: According to Novick classification for IVC thrombus there were 10 diaphragmatic (level IV), 20 retro-hepatic (level III), and 25 infra-hepatic (level II or I) tumor thrombus. Vena Cava reconstruction was completed in 54 (98%) patients with one patient deemed unresectable. Vena cava control required cardiac bypass (n=10), veno-venous bypass (n=4) or infrahepatic IVC control (n=40). Reconstruction of IVC was completed with two prosthetic interposition grafts done for one stage IV and one stage III thrombus, 2 patch repairs done for stage III thrombus, and 50 primary IVC repairs. VTE prophylaxis involved sequential compression devices (n=54), unfractionated or fractionated heparin (n=17). Anticoagulation with heparin and warfarin was administered for two patients with postoperative pulmonary embolus and one patient with chronic bilateral ileo-femoral venous thrombosis. No other hosptial VTE events occured and all other IVC reconstructions were patent at a mean follow-up of 23 months. A single asymptomatic patient with primary ICV repair had estimated 30% IVC narrowing but no other measureable stenosis as detected by postoperative imaging. Three patients required reoperation (2 for surgical site bleeding, 1 for small bowel fistula). Early surgical complications included CDC Grade I, (n=3), II (n=6), IIIa,(n=2), IIIb (n= 3),and V (n=2). Regional retroperitoneal or distant recurrent RCC occurred in 26 (48%) patients with a single patient demonstrating recurrent IVC tumor thrombus at 8 months requiring secondary IVC thrombectomy. All patients with tumor invasion of the IVC wall developed recurrent RCC and no patient survived 5-years. Early mortality was 3.6% (n=2) with an additional 27 (49%) patients dying within 24 months and an overall group mortality of 80% (n=44) during surveillance.
CONCLUSIONS: A multi-disciplinary approach for perioperative management of advanced RCC helps optimize surgical outcomes. Primary IVC repairs are possible in most patients and IVC patency is good without use of complex anticoagulation protocols. Early IVC recurrent thrombus rates are low, however RCC tumor recurrence and mortality is high among advanced cancers with IVC wall invasion.